Current Women's Health Reviews - Volume 4, Issue 3, 2008

In the 1980s, I was working on a health and nutrition program for the inhabitants of coffee plantations (fincas) in the highlands of the west coast of Guatemala. One night, around 8 p.m., a nurse in charge of one of these fincas called me with an emergency. When we entered the dwelling, in a unique room where the family would eat, cook and sleep, I saw a table placed in the centre of the room, with a boy lying on this table surrounded by candles. The boy was around 8 years old, thin, with impressive beautiful black eyes, breathing slowly. Seated on the floor in silence, forming a circle around the table, were some women and men dressed in colourful indigenous clothing. Any new person coming into the room lit a candle and took a seat in the same way. We could not convince the parents to allow us to take care of the child, to take him to the hospital and treat him. Their refusal was based on accumulated experiences in the community: the child would die anyway in the hostile hospital, and in order to receive his dead body and bury him, the family would need to pay to a mortuary company a sum of money unaffordable for them. Allowing the child to die at home would give them the opportunity to bury their child in a family cemetery without costs. Coming out of this dwelling with our hearts destroyed, we could see the mansion where the owner of the finca lived—the windows were lit, and we could hear the sound of soft music and the noise of knives and forks, which were sometimes interrupted by laughs. The next day, the nurse reported to us that the child had died around 2 a.m. Health workers around the world are faced with different aspects of health inequities as the one described above. The role of social and economic situation on health deliver and outcome is a well-known situation for health providers. Recent epidemiological research has shown that fetal growth has long term implications on the quality of life of an individual. Two articles in this issue show the implications of fetal life. Prater article describes the effect of maternal nutrition on long term outcomes of the progeny and Maritz article shows the long-term effect on lung integrity of the offspring of maternal nicotine exposure. Again, another contribution on how inequities could influence quality of life since it is expected that low income populations would have poorer fetal growth and low possibility to receive preventive interventions to improve maternal habits. Hallam article shows an initiative from a high income country to address health inequities during pregnancy. It is an interesting approach since the author has look for evidence based interventions that can be applied in a high income country and could ameliorate the differences in outcome due to inequities. In middle and low income countries a set of evidence based interventions could have a great impact on maternal survival and the challenge is how to improve the implementation of such interventions. Implementation science is a young science promoting research looking for mechanisms to scale-up well known interventions of benefit. Such approach is described in Chersich article testing a simple intervention to improve the access to HIV testing for women. It is highly encouraging to see the effort of the medical scientific community to ameliorate the consequences of health inequities and to improve survival and quality of life of those with major needs.

Introduction: Evidence is mounting to suggest that maternal nutritional factors during pregnancy will have both short- and long-term consequences to the health of the child. Recent studies show a direct connection between gestational environment (nutrition, chemical exposure, stress, and exercise) and elevated risk of chronic disease in the adult offspring, many decades later. These studies strongly emphasize the importance of proper prenatal care and nutrition as they relate to both improved neonatal outcome, and long-term adult health of the child. Objective: The objective of this article is to provide a comprehensive review of the relationship between prenatal nutritional choices and relative risk of chronic disease in adult offspring. Methods: A systematic search of the literature was performed and reviewed, that focused on gestational nutritional aspects that are thought to substantially relate to birth outcome and risk of adult-onset chronic central nervous, cardiovascular, reproductive, musculoskeletal, immune, metabolic, and neoplastic diseases in offspring. Three databases were searched and relevant original works, retrospective and prospective studies, and review articles from all available years were selected; studies involving human subjects and animal models of human disease were included, whereas veterinary studies were excluded. Databases searched included Pub Med, Biological Abstracts from Ovid, and CAB Abstracts. The major MeSH search terms for Pub Med were “embryonic and fetal development”, with “physiology, immunology, and genetics” as subheadings, AND “prenatal nutrition” with same subheadings; this search yielded 27 results. Search terms constructed in Biological Abstracts included “fetal programming AND nutrition”, and yielded 559 results. Results of search using “fetal programming” search term in CAB Abstracts from CAB Direct yielded 132 results. Results and Discussion: The theory of the “developmental origins of health and disease” was coined by David Barker, and suggests that maternal environment can alter fetal programming during times of genetic plasticity, and modify the trajectory of development into adulthood. This theory hypothesizes that the fetus adapts to a suboptimal gestational environment by choosing pathways of gene expression and cell differentiation resulting in adoption of a structure, physiologic state, or behavior that best suits the current situation. This results in manifestation of an alternate thrifty phenotype in anticipation of possible future suboptimal postnatal environments. However, if the postnatal environment does not accurately reflect what was anticipated by the fetus prenatally, the epigenetic changes adopted by the child before birth may inadequately prepare him or her for healthy postnatal life. The phenotypic changes that result from adverse maternal caloric, protein, carbohydrate, fat, or micronutrient intake, are thought to not be repaired postnatally, and unwittingly predispose the adult offspring to a higher incidence of cognitive dysfunction, obesity, hypertension, diabetes mellitus, immune dysfunction, infertility, cardiovascular disease, osteoporosis, and cancer. Putative mechanisms and current theories are discussed in this review.

Nicotine occurs in tobacco smoke. It is a habit forming substance and is prescribed by health professionals to assist smokers to quit smoking. It is rapidly absorbed from the lungs of smokers. It crosses the placenta and accumulates in the developing fetus. Nicotine induces formation of oxygen radicals and at the same time also reduces the anti-oxidant capacity of the lungs. Nicotine and the oxidants cause point mutations in the DNA molecule thereby changing the program that controls lung growth and maintenance of lung structure. The data available indicate that maternal nicotine exposure induces a persistent inhibition of glycolysis and a drastic increased cAMP level. These metabolic changes are thought to contribute to the faster aging of the lungs of the offspring of mothers that are exposed to nicotine via the placenta and mother's milk. The lungs of these animals are more susceptible to damage as shown by the gradual deterioration of the lung parenchyma. The rapid metabolic and structural aging of the lungs of the animals that were exposed to nicotine via the placenta and mother's milk, and thus during phases of lung development characterized by rapid cell division, is likely due to “programming” induced by nicotine and not by inadequate placental perfusion pressure and nutrient supply. It is therefore not advisable to use nicotine during gestation and lactation.

Introduction: This paper presents a summary of what is known about the effectiveness of interventions to address health inequalities during pregnancy. The research was carried out as part of a wider review of the literature relating to interventions to address inequalities in the early years. This contributed to the work of Scotland's Ministerial Task Force on Health Inequalities, which reported in June 2008. Objectives: The objectives of this article are to provide a broad summary of the evidence base; highlight the known effectiveness of specific interventions; and identify gaps. Methods: The review is based on analysis of data from publications/work in progress recommended and/or produced by the Scottish Government, its agencies and those conducting relevant research within universities and other organisations across Scotland. Findings: Evidence supports school and community-based sex and relationship education as effective in averting pregnancy at a young age. During pregnancy, intensive and direct interventions, such as vouchers and provision of food, have a greater chance of improving nutritional status than simply providing advice and information. Multi-faceted initiatives (information, advice and counselling) are more likely to be effective in addressing smoking cessation than a single service. Antenatal care programmes may improve outcomes for both teenage mothers and their infants, but little research has been carried out on the content of antenatal classes, and there is little evidence relating to Scotland or to the rest of the UK. Conclusions: There is good evidence to show the effectiveness of a range of initiatives, both at the level of the population and the individual, although the most vulnerable groups are inevitably the most difficult to engage. Tapping into the popularity of computer games and other technological approaches may help young people engage with issues relating to relationships and the care of young infants, although initiatives have yet to be evaluated in the UK. Families who are hard to reach by traditional services may feel more comfortable receiving antenatal home visits from volunteers within their own community, although it is important that such volunteers receive appropriate training and support.

Only small proportions of women are aware of their HIV status and can enter HIV treatment and care. The remainder cannot access essential HIV services, placing them at high-risk for early death and facilitating HIV transmission. To rectify this, many international organisations now recommend routine HIV testing in clinical settings. Provider-patient encounters in reproductive health services provide an ideal opportunity and conducive environment for testing. While rapid HIV tests, with results available the same day, have simplified testing, insufficient efforts have been made to modify pre- and post-test counselling. We argue for increased emphasis on group pre-test information given during health talks, especially in antenatal and child health clinics. Brief individual pre-test sessions would then only be for confirming information was comprehended. Little evidence supports effectiveness of behaviour change counselling for HIV-negatives. Consequently, more abbreviated and focused post-test information (or printed leaflets) could be given for those testing negative. Conversely, substantial evidence shows post-test counselling for HIV-positives is effective, and should be prioritised and meet pre-set standards of quality. Though attention is needed to ensure high-quality interventions before and after testing, simplifying pre-test information and post-test information for negatives could facilitate a rapid increase in testing coverage and frequency.

Background and Objective: Botulinum neurotoxin (BoNT), now commonly used for reducing muscular spasms in other neuromuscular disorders, is now increasingly proposed also for treating pelvic floor disorders, including chronic pelvic pain syndromes, vaginismus, vulvodynia and vulvar vestibulitis syndrome. To provide up-to-date information on these advances we reviewed the literature about BoNT injections for pain and spasms related to pelvic floor disorders. Methods: We conducted a Medline search using the terms botulinum neurotoxin, pelvic floor disorders, levator ani myalgia, vaginismus, vulvar vestibulitis, vulvodynia, dyspareunia, interstitial cystitis, recurrent cystitis, and postcoital cystitis. We sought information on the indications and techniques used for BoNT treatment for pelvic floor dysfunctions, and related pain syndromes in women. Results: Our search identified 12 studies for review (including a randomized controlled trial) showing that BoNT effectively reduces pain in chronic genital pain syndromes associated with pelvic floor spasm. Before BoNT trials, patients with idiopathic lifelong vaginismus and dyspareunia, associated with hyperactive pelvic floor muscles, had no effective treatment options. BoNT injected under electromyographic (EMG) guidance in pelvic floor muscles improves vaginismus, helping to restore a normal sexual life. BoNT injections also seem to improve vulvodynia and vulvar vestibulitis. Though some patients need periodic injections, in about 65% of affected women BoNT achieves permanent benefit. Conclusions: These encouraging evidence-based results suggest that BoNT injected intramuscularly should extend treatment options for women with lifelong or acquired pelvic floor disorders and genital pain.

Endometriosis is an enigmatic, debilitating disease which affects as many as 15% of all women of reproductive age and is characterized by pelvic pain and infertility. Current treatment regimes used to manage the disease do so by inducing a hypoestrogenic state. While the absence of circulating estrogen levels lead to a regression of the disease, this hypoestrogenism also induces many unpleasant side-effects. As such, these and other shortcomings of current drug therapies emphasize their limitations and the necessity for the development of novel endometriosis treatments. In this review, current therapies for medical management of endometriosis are discussed as are their shortcomings. Potential target areas which may be attractive alternatives to current therapies are also reviewed. Emphasis is placed upon the emerging research using TNF inhibitors, their potential benefits over current treatment regimes and the development of future potential therapeutic targets.

Despite years of intensive investigation that has been made in understanding women's susceptibility to breast cancer, it remains a major cause of death worldwide. In mathematical terms, breast cancer can be outlined as a non-linear system that advances in time and in space through different states and a number of transitions from one state to another over a certain time interval. Breast cancer emerges from multiple spontaneous and/or inherited alterations that induce changes in expression patterns of genes and proteins that function in complex networks controlling critical cellular events. Here, we discuss breast cancer as a dynamical disease using the basic principles of the mathematics of non-linear systems and chaos theory. Additionally, some of the critical concepts necessary to give meaning to its underlying physical complexity are introduced. This way of thinking may help to clarify concepts, indicate alternative experiments and categorie the actual knowledge.

Puerperal ovarian vein thrombosis (POVT) is an uncommon but potentially fatal complication of post gynecological surgery, which is often diagnosed by clinical findings and indirect radiologic signs. Ultrasound (US) and multislice computed tomography (MCT) imaging now offer reliable and accurate methods for suspected POVT. We present here a case of postcaesarean ovarian vein thrombosis and describe its clinical and radiological findings. Differential diagnosis and management are discussed.